UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Karoline Tamoney
MSI & MSII PATIENT ASSESSMENT TOOL .
 1 PATIENT INFORMATION
Assignment Date: 2/27/15
Agency: TGH
Patient Initials: SL
Age: 25 y.o
Admission Date: 02/11/15
Gender: Male
Marital Status: Single
Primary Medical Diagnosis
Primary Language: English
Appendicitis 541
Level of Education: Currently attends the pharmacy program at
University of South Florida
Other Medical Diagnoses: (new on this admission)
None
Occupation (if retired, what from?): Currently a student at the University
of South Florida
Number/ages children/siblings: Patient is an only child and has no
children
Served/Veteran: No
If yes: Ever deployed? Yes or No
Code Status: Full
Living Arrangements: Patient lives in a two-story house in Tampa
Fl with his mother, his girlfriend, and two dogs.
Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date: 02/11/15
Procedure:
Laparoscopic Appendectomy
Culture/ Ethnicity /Nationality: Caucasian Non-Hispanic American
Religion: Catholic
Type of Insurance: BlueCross Blue Shield
 1 CHIEF COMPLAINT: “I am having some abdominal discomfort today.”
 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
SL is a 25-year-old male pharmacy student who presents to the ED with complaints of RLQ pain. The pain began 8 hours
prior to arrival to the ED (2/10/15 at 7:30pm), and woke him up from sleep 2 hours prior to admission (2/11/15 at
1:00am). The pain is described as a constant, sharp jabbing pain, and the pain is not relieved nor worsened and remains a
constant 10 out of 10 on the pain scale. Prior to arrival, the patient did not attempt any interventions to relieve the pain,
but was quickly awaken during the night due to an increased pain. He reports 5 episodes of emesis and night sweats. He
denies fevers. He reports having mild back pain prior to abdominal pain.
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 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Date
N/A
N/A
02/11/15
 1 IMMUNIZATION HISTORY
(May state “U” for unknown, except for Tetanus, Flu, and Pna)
YES
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria
Adult Tetanus (U)
Influenza (flu) (November 2014)
Pneumococcal
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state “U” for the patient not knowing date received
 1 ALLERGIES
OR ADVERSE
REACTIONS
Medications
NAME of
Causative Agent
Stroke
Glaucoma
Diabetes
Cancer
Asthma
Arthritis
Alcoholism
Cause
of
Death
(if
applicable
)
55 Father is
Father
y.o still alive
50 Mother is
Mother
y.o still alive
Patient’s mother has seasonal allergies.
The patient states he is unaware of his father’s medical history because he is not in contact with his father.
Tumor
Hypertension
Kidney
Problems
Mental
Health
Problems
Seizures
Stomach
Ulcers
(angina, MI, DVT etc.)
Gout
Heart Trouble
Bleeds Easily
Environmenta
l Allergies
Anemia
Age (in years)
2
FAMILY
MEDICAL
HISTORY
Operation or Illness
Rheumatic arthritis
Tendon repair left hand
Laparoscopic Appendectomy
NO
Type of Reaction (describe explicitly)
None
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None
Other (food, tape,
latex, dye, etc.)
 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Appendicitis occurs in 7 % of the U.S population. It is an acute inflammation of the vermiform appendix. Appendicitis
occurs when the appendix becomes obstructed or inflamed. The appendix is a small appendage of the cecum, and fills and
empties with intestinal content. An obstruction may occur from a fecalith, a foreign body, fibrous disease of the bowel
wall, an infestation of parasites, or the twisting of the appendix by adhesions. 60% of appendicitis’ occur from hyperplasia
of the submucosal lymphoid follicles, and 35% with fecal stasis. As the appendix becomes inflamed, veins become
engorged, and arterial occlusion occurs. Bacteria then starts to accumulate, and the appendix can develop gangrene. The
occurrence of an appendicitis causes inflammation of the right lower quadrant of the abdomen. Appendicitis is a surgical
emergency, and has a mortality rate of 0.2% to 0.8%. The risk of appendicitis is increased in first-degree relatives
affected. The risk also increases with inherited predisposition to obstruction in the lumen of the appendix. Appendicitis is
typically seen in patients between the ages of 20-30, and is more common in men than it is in women. An incidence of
appendix perforation is higher in individuals younger than 18 and individuals older than 50, due to a delayed diagnosis.
Ethnicity and race have no known effect of developing appendicitis. Appendicitis is more common in developed countries
due to low fiber diets, high sugar diets, family history, as well as infection. Patients with appendicitis complain of right
lower quadrant abdominal pain, but if perforation has occurred a more generalized pain may be described. Patients also
complain of anorexia, nausea, vomiting, abdominal distention, as well as constipation. An elevation in temperature is also
common (usually 100-101F). Diagnosis test to confirm the occurrence of an appendicitis include an abdominal
ultrasonography, flat-plate abdominal x-ray, a complete blood count, computed tomography of the abdomen with or
without contrast, C reactive protein. Treatment for appendicitis includes surgical interventions, which can either be an
open appendectomy or a laparoscopic appendectomy. (Unbound Medicine, 2014).
 5 MEDICATIONS: [Include both prescription and OTC; hospital (include IVF) , home (reconciliation),
routine, and PRN medication . Give trade and generic name.]
Name Docusate Sodium (Colace)
Concentration
Dosage Amount 100mg
Route Oral
Frequency 2 times a day
Pharmaceutical class Stool Softener
Home
Hospital
or
Both
Indication Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery).
Adverse/ Side effects EENT: throat irritation
GI: mild cramps, diarrhea
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Derm: rashes
Nursing considerations/ Patient Teaching
Advise patients that laxatives should be used only for shortterm therapy. Long-term therapy may cause electrolyte imbalance and dependence.
Encourage patients to use other forms of bowel regulation, such as increasing bulk in the diet,
increasing fluid intake (6–8 full glasses/day), and increasing mobility. Normal bowel habits are variable
and may vary from 3 times/day to 3 times/wk.
Instruct patients with cardiac disease to avoid straining during bowel movements (Valsalva
maneuver).
Advise patient not to use laxatives when abdominal pain, nausea, vomiting, or fever is present.
Advise patient not to take docusate within 2 hr of other laxatives.
Name Levofloxacin (Levaquin)
Concentration 500mg g in Sodium Dosage Amount 500mg:100 mL/hr
Chloride 0.9% 100mL/hr
Route Intravenously
Frequency Every 24 hours
Pharmaceutical class fluoroquinolones
Home
Hospital
or
Both
Indication Treatment of the following bacterial infections:
Urinary tract infections, including cystitis, pyelonephritis, and prostatitis,
Respiratory tract infections, including acute sinusitis, acute exacerbations of chronic bronchitis,
community-acquired pneumonia, and nosocomial pneumonia, Uncomplicated and complicated skin and
skin structure infections.
Adverse/ Side effects CNS: ELEVATED INTRACRANIAL PRESSURE (INCLUDING PSEUDOTUMOR CEREBRI),
SEIZURES, agitation, anxiety, confusion, depression, dizziness, drowsiness, hallucinations, headache, insomnia,
nightmares, paranoia, tremor
CV: TORSADE DE POINTES, QT interval prolongation
GI: HEPATOTOXICITY, PSEUDOMEMBRANOUS COLITIS, nausea, abdominal pain, diarrhea, vomiting
GU: vaginitis
Derm: STEVENS-JOHNSON SYNDROME, photosensitivity, rash
Endo: hyperglycemia, hypoglycemia
Local: phlebitis at IV site
Neuro: peripheral neuropathy
MS: arthralgia, tendinitis, tendon rupture
Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS
Nursing considerations/ Patient Teaching
Instruct patient to take medication as directed at evenly
spaced times and to finish drug completely, even if feeling better. Take missed doses as soon as
possible, unless almost time for next dose. Do not double doses. Advise patient that sharing of this
medication may be dangerous.
Advise patients to notify health care professional immediately if they are taking theophylline.
Encourage patient to maintain a fluid intake of at least 1500–2000 mL/day to prevent
crystalluria.
Advise patient that antacids or medications containing calcium, magnesium, aluminum, iron, or
zinc will decrease absorption and should not be taken within 4 hr before and 2 hr after taking this
medication.
May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring
alertness until response to medication is known.
Advise patient to notify health care professional of any personal or family history of QTc
prolongation or proarrhythmic conditions such as recent hypokalemia, significant bradycardia, or recent
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myocardial ischemia or if fainting spells or palpitations occur. Patients with this history should not
receive levofloxacin.
Advise patient to stop taking levofloxacin and notify health care professional immediately if signs
and symptoms of peripheral neuropathy occur.
Caution patient to use sunscreen and protective clothing to prevent phototoxicity reactions
during and for 5 days after therapy. Notify health care professional if a sunburn-like reaction or skin
eruption occurs.
Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching
or discharge, loose or foul-smelling stools).
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal
products being taken and to consult with health care professional before taking other medications.
Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool
contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care
professional.
Instruct patient to notify health care professional immediately if rash, jaundice, signs of
hypersensitivity, or tendon (shoulder, hand, Achilles, and other) pain, swelling, or inflammation occur. If
tendon symptoms occur, avoid exercise and use of the affected area. Increased risk in >65 yr old, kidney,
heart and lung transplant recipients, and patients taking corticosteroids concurrently. Therapy should be
discontinued.
Name Metronidazole (Flagyl)
Concentration 500mg g in Sodium Dosage Amount 500mg 100mL/hr
Chloride 0.9% 100mL/hr
Route Intravenous
Frequency Every 24 hours
Pharmaceutical class Anti-infective
Home
Hospital
or
Both
Indication Treatment of the following anaerobic infections:
Intra-abdominal infections (may be used with a cephalosporin), Gynecologic infections, Skin and
skin structure infections, Lower respiratory tract infections, Bone and joint infections, CNS infections,
Septicemia, Endocarditis.
Adverse/ Side effects CNS: SEIZURES, dizziness, headache, aseptic meningitis (IV), encephalopathy (IV)
EENT: optic neuropathy, tearing (topical only)
GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting
Derm: STEVENS-JOHNSON SYNDROME, rash, urticariatopical only: burning, mild dryness, skin irritation,
transient redness
Hemat: leukopenia
Local: phlebitis at IV site
Neuro: peripheral neuropathy
Misc: superinfection
Nursing considerations/ Patient Teaching Instruct patient to take medication as directed with evenly spaced
times between doses, even if feeling better. Do not skip doses or double up on missed doses. Take
missed doses as soon as remembered if not almost time for next dose.
Advise patients treated for trichomoniasis that sexual partners may be asymptomatic sources of
reinfection and should be treated concurrently. Patient should also refrain from intercourse or use a
condom to prevent reinfection.
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Caution patient to avoid intake of alcoholic beverages or preparations containing alcohol during
and for at least 3 days after treatment with metronidazole, including vaginal gel. May cause a disulfiramlike reaction (flushing, nausea, vomiting, headache, abdominal cramps).
May cause dizziness or light-headedness. Caution patient to avoid driving or other activities
requiring alertness until response to medication is known.
Instruct patient to notify health care professional promptly if rash occurs.
Inform patient that medication may cause an unpleasant metallic taste.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal
products being taken and to consult with health care professional before taking other medications.
Advise patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may
minimize dry mouth. Notify health care professional if dry mouth persists for more than 2 wk.
Inform patient that medication may cause urine to turn dark.
Advise patient to consult health care professional if no improvement in a few days or if signs and
symptoms of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or
foul-smelling stools) develop.
Name Sodium Chloride 0.9% 500 mL Concentration 500mL Sodium
Dosage Amount 500 mL/hr
Bolus
Chloride 0.9% 500mL/hr
Route Intravenous
Frequency Continuous
Pharmaceutical class mineral and electrolyte
Home
Hospital
or
Both
replacements/supplements
Indication Hydration and provision of NaCl in deficiency states.
Maintenance of fluid and electrolyte status in situations in which losses may be excessive (excess
diuresis or severe salt restriction). 0.9% ("normal saline") solution is used for: Replacement, Treatment
of metabolic alkalosis, A priming fluid for hemodialysis, To begin and end blood transfusions. Small
volumes of 0.9% NaCl (preservative-free or bacteriostatic) are used to reconstitute or dilute other
medications.
Adverse/ Side effects CV: HF, PULMONARY EDEMA, edema
F and E: hypernatremia, hypervolemia, hypokalemia
Local: IV: extravasation, irritation at IV site
Nursing considerations/ Patient Teaching
Explain to patient the purpose of the infusion.
Advise patients at risk for dehydration due to exposure to extreme temperatures when and how to take NaCL
tablets. Inform patients that undigested tablets may be passed in the stool; oral electrolyte solutions are
preferable.
Name Simethicone (Mylicon)
Concentration
Dosage Amount 80 mg
Route Oral Chewable
Frequency E 8hr PRN
Pharmaceutical class antiflatulent
Home
Hospital
or
Both
Indication Relief of painful symptoms of excess gas in the GI tract that may occur postoperatively or as a
consequence of: Air swallowing, Dyspepsia, Peptic ulcer, Diverticulitis.
Adverse/ Side effects None significant
Nursing considerations/ Patient Teaching Explain to patient the importance of diet and exercise in the
prevention of gas. Also explain that this medication does not prevent the formation of gas. Advise
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patient to notify health care professional if symptoms are persistent.
Name Oxycodone acetaminophen
Concentration
Dosage Amount1-2tb
(Percocet)
Route Oral
Frequency E 4 hr PRN
Pharmaceutical class Opiod agonist
Home
Hospital
or
Both
Indication Moderate to severe pain; extended release product should be used for patients requiring aroundthe-clock management of chronic pain.
Adverse/ Side effects CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations,
headache, unusual dreams
EENT: blurred vision, diplopia, miosis
Resp: RESPIRATORY DEPRESSION
CV: orthostatic hypotension
GI: constipation, dry mouth, choking, GI obstruction, nausea, vomiting
GU: urinary retention
Derm: flushing, sweating
Misc: physical dependence, psychological dependence, tolerance
Nursing considerations/ Patient Teaching
Instruct patient on how and when to ask for and take pain
medication.
Advise patient that oxycodone is a drug with known abuse potential. Protect it from theft, and
never give to anyone other than the individual for whom it was prescribed.
Medication may cause drowsiness or dizziness. Advise patient to call for assistance when
ambulating or smoking. Caution patient to avoid driving and other activities requiring alertness until
response to medication is known.
Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool.
Advise patient to make position changes slowly to minimize orthostatic hypotension.
Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or
herbal products being taken and consult health care professional before taking any new medications.
Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.
(Unbound Medicine, 2014)
 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital? NPO
Analysis of home diet (Compare to “My Plate” and
Diet patient follows at home? Patient states not following a Consider co-morbidities and cultural considerations):
diet at home
24 HR average home diet:
The patient should be eating 6 ounces of grains a day, 2 ½
cups of vegetables a day, 2 cups of fruit a day, 3 cups of
dairy a day, 5 ½ ounces of protein a day, and 6 tsp. of oil.
Currently the patient is maintaining a very healthy and
nutritious diet. However, the patient is not receiving the
proper amounts of daily fruits. The patient should be
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consuming 2 cups of fruit daily. Also, the patient should
consume 3 cups of dairy daily. However, until a full
recovery is made, the patient should begin a liquid diet,
slowly increasing to a soft food only diet, and advancing to
a normal diet when soft foods are tolerated and the patient
is able to tolerate a solid food diet (My Plate 2015).
Breakfast:4 eggs and 5 strips of bacon
Lunch: Two slices of turkey, one slice of ham, one piece of
American cheese, tomato, lettuce, and a little dab of
mustard on whole grain bread
Dinner: One or two grilled pieces of chicken with a cup of
mashed potatoes as well as a cup of green beans
Snacks: Peanut butter and crackers
Liquids (include alcohol): In the morning: A glass of
orange juice. Throughout the day I typically will only drink
water. On the weekends I will usually have one or two cans
of beer.
Use this link for the nutritional analysis by comparing
the patients 24 HR average home diet to the
recommended portions, and use “My Plate” as a
reference.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your
discussion)
Who helps you when you are ill? “Well, I live with my mom and my girlfriend so usually when I need help one of them or
both of them will help me.”
How do you generally cope with stress? or What do you do when you are upset? “I usually try to not be by myself
whenever I am upset. I like to go to the gym and play basketball with my friends when I am getting stressed. I also like to
sleep or just watch a movie when school is really stressing me out.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“School is very overwhelming.”
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
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unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”
Have you ever felt unsafe in a close relationship? _No______________________________________________________
Have you ever been talked down to?__No_____________ Have you ever been hit punched or slapped?
No______________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
______No____________________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship? I am currently in a safe relationship
 4 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust
Intimacy vs. Isolation
Autonomy vs.
Generativity vs.
Doubt & Shame
Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair
Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s
developmental stage for your
patient’s age group: “The developmental task is to form positive close relationships with others. Erikson
describes intimacy as finding one’s self but losing one’s self in another. The hazard of this stage is that one will
fail to form an intimate relationship with either a romantic partner or through friendship and thus become
socially isolated. For such individuals loneliness becomes a looming problem”(Osborn, 2010, pg 253). .
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your
determination:
This patient had developed a very close relationship with his partner. The two have been living together for a year at his
mothers’ house, and plan on getting their own apartment once they finish school. SL stated, “I do not know what I would
do without her. She has always been there for me through difficult situations, and I am thankful to have her.” He also
described how grateful he is for his mother and the close relationship he has with her, as well as the relationship he has
with his friends. This patient is currently in the intimacy stage of his life. He has developed very close relationships, both
romantic and friendship relationships, and stated during the assessment of stress that “I usually try not to be by myself
when I am upset”. Instead he resorts to spending time with his friends and family.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of
life:
The patient’s hospitalization has helped to strengthen his relationship with his girlfriend. The experience has brought them
closer together and he states “I know that I can always count on her…. she’s been here with me through all of this.”
+3 CULTURAL ASSESSMENT:
“What do you think is the cause of your illness?” “I don’t really know why this happened.”
What does your illness mean to you? “Being ill shows me how lucky I am to have a great support system. I have my
girlfriend or my mom here everyday to help me recover. I am truly thankful for that. Not everyone is as lucky as I am.”
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+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”
Have you ever been sexually
active?_Yes___________________________________________________________________
Do you prefer women, men or both genders?
__Women_________________________________________________________
Are you aware of ever having a sexually transmitted
infection? No_______________________________________________
Have you or a partner ever had an abnormal pap
smear?__No___________________________________________________ Have you or your partner received the
Gardasil (HPV) vaccination? _____Yes______________________________________
Are you currently sexually active? _Yes__________________________ If yes, are you in a monogamous relationship?
__Yes__________________ When sexually active, what measures do you take to prevent acquiring a sexually transmitted
disease or an unintended pregnancy? _Condoms_________________________________
How long have you been with your current partner?_Two
years_______________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity?
_No__________________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
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±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_”Religion plays a huge role in my life. I think everyone should believe in something, it gives life
meaning.”_________________________________________________________________________________
____________________
__________________________________________________________________________________________
____________
Do your religious beliefs influence your current condition?
_”Yeah, when I am sick I know that God is right by my side and that he is looking out for me. I know that this
is apart of his plan for me, and I trust him.”
__________________________________________________________________________________________
___________
__________________________________________________________________________________________
____________
+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Yes
No
For how many years? X years
(age
thru
)
If applicable, when did the
patient quit?
Pack Years:
Does anyone in the patient’s household smoke tobacco? If
so, what, and how much? Patient states he does not live with
anyone that smokes tobacco.
Has the patient ever tried to quit? Patient does not smoke.
If yes, what did they use to try to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
How much? One or two cans on the
What? Budweiser Beer
weekend.
Volume: 4.0%
Frequency: Two times a week
If applicable, when did the patient quit?
Patient currently drinks one or two cans of
beer a week
For how many years?4
(age 21
thru 25
)
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age
Is the patient currently using these drugs?
Yes No
thru
)
If not, when did he/she quit?
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
I have not been exposed to any occupational hazards.
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 10 REVIEW OF SYSTEMS NARRATIVE
Gastrointestinal
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:50
Bathing routine: Daily
Other:
Be sure to answer the highlighted area
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Immunologic
Nausea, vomiting, or diarrhea
Constipation
Irritable
Bowel
GERD
Cholecystitis
Indigestion
Gastritis /
Ulcers
Hemorrhoids
Blood in
the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy? Has not had
one
Other:
Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 10
or so
x/day
Bladder or kidney infections
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
3
Routine dentist visits
x/year
2
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic
reaction
Enlarged lymph nodes
Other:
Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
Metabolic/Endocrine
Diabetes
x/day
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:
Vision screening Once every year
Other:
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Central Nervous System
WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
Environmental allergies
menarche
age?
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
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last CXR? U
Other:
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when? U
Other:
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density &
MEN ONLY
Result:
Infection of male
genitalia/prostate?
Frequency of prostate exam?
Annually
Date of last prostate exam? A
year ago
BPH
Urinary Retention
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
General Constitution
Recent weight loss or gain
How many lbs?
Time frame?
Intentional?
How do you view your overall health?
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
None
Any other questions or comments that your patient would like you to know?
None
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±10 PHYSICAL EXAMINATION:
General Survey: Patient
is a well developed 25
year-old male who was
admitted to TGH due to
appendicitis
Temperature: 98 (Orally)
Height 182.9 cm (6 ft)
Pulse 99
Respirations 18
SpO2 98%
Weight 83.92kg (185 BMI 24
lb)
Blood Pressure: 127/76 (left arm)
Pain: (7/10) Patient states “I
am experiencing abdominal
discomfort.”
Is the patient on Room Air or O2 Room
Air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
talkative
quiet
boisterous
flat
apathetic
bizarre
agitated
anxious
tearful
withdrawn
aggressive
hostile
loud
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
If anything is not checked, then use the blank spaces to
describe what was assessed in the physical exam that
was not WNL (within normal limits)
Peripheral IV Site Type: Left Peripheral IV
Location: Left Arm
Date inserted:
2/13/15
Fluids infusing?
no
yes - what? Sodium Chloride 0.9% 500 mL Bolus
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size 3/ mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 5
inches & left ear- 5
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: None
Comments:
Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
symmetric
Percussion resonant throughout all lung fields, dull towards posterior bases
Sputum production: thick thin
Amount: scant small moderate large None
Color: white pale yellow yellow dark yellow green gray light tan brown red
Lung sounds:
RUL Clear
LUL Clear
RML Clear
LLL Clear
RLL Clear
Chest expansion
CL – Clear; WH – Wheezes; CR – Crackles; RH – Rhonchi; D – Diminished; S – Stridor; Ab - Absent
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Cardiovascular:
No lifts, heaves, or thrills
Heart sounds:
S1 S2 audible
Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze)
No JVD
Calf pain bilaterally negative
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3+
Carotid: 3+
Brachial: 3+
Radial: 3+
Femoral: 3+
Popliteal: 3+
DP: 3+
PT: 3+
No temporal or carotid bruits
Edema:
None
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Last BM: (date 2
/ 10
/ 15
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Nausea
emesis Describe if present: Currently not present.
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other – Describe:
GU
Urine output:
Clear
Cloudy
Color: light yellow
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance
CVA punch without rebound tenderness
Previous 24 hour output: 30 mL/hr
or
with assistance
Musculoskeletal:  Full ROM intact in all extremities without crepitus
Strength bilaterally equal at 5 _______ RUE ___5 ____ LUE __5 _____ RLE & _5 ______ in LLE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or paresthesia
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:
+2
Biceps: +2
Brachioradial: +2
Patellar:
+2
Achilles:
+2
Ankle clonus: positive negative Babinski:
positive negative
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±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
WBC
20.13
13.86
13.89
Dates
(2/11/15)
(2/12/15)
(2/13/15)
Neutrophils
88.8
85.4
87.9
(2/11/15)
(2/12/15)
(2/13/15)
Lymphocytes
6.3
10.0
5.9
(2/11/15)
(2/12/15)
(2/13/15)
Trend
Upon admission the
patient’s WBC was
elevated significantly.
The normal WBC range
is between 5-10. On
2/12/15, the patient’s
WBC decreased but still
remains elevated. On
2/13/15 WBC remained
elevated, and increased
from the previous day.
The normal neutrophil
range is between 30007500. Upon admission
the patient’s neutrophil
levels were elevated. On
2/12/15, neutrophil levels
decreased but still
remained elevated. On
2/13/15 neutrophil levels
remained elevated, and
increased from the
previous days values.
Analysis
An increase in WBC
would indicate that an
infection has occurred
from a bacterial
invasion due to the
patient presenting with
a ruptured appendix.
An increase in
neutrophil levels
indicates that the body’s
first defense
(neutrophils) have
responded to a present
pathogen and are
responding to the
affected area. If a
bacterial infection has
occurred, bone marrow
will produce large
numbers of these cells.
1500-4500 is the normal A decrease in
lymphocyte range. Upon lymphocyte count
admission the patient
indicates that the body
presented with a
is low on infectious
decrease in
resistance. Therefore,
lymphocytes. On
the body is susceptible
2/12/15, lymphocyte
to infections. Decreased
levels increased, but
lymphocyte count can
decreased again the
lead to damage of
following day.
organs.
2/11/15 CT Abdomen Pelvis W IV Contrast Only
Thorax-A 7 mm left lower lung pulmonary nodule is best seen on axial image 23. The visualized lung bases
are otherwise clear. The visualized cardiac structures are within normal limits.
Abdomen-The liver is normal size and contour without focal lesion. Gallbladder is unremarkable. The
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16
spleen, adrenals, kidneys, and pancreas normal appearance. Hiatal hernia.
Stomach, duodenum, small bowel normal appearance without evidence of mass or inflammation. The
appendix is enlarged measuring up to 9mm in diameter, with peripheral contrast enhancement and
adjacent inflammatory changes. Cecum shows pericecal inflammatory changes. Adjacent fluid and free
fluid in the pelvis. The colon is unremarkable. Abdomen vasculature within normal limits. No
pathologically enlarged lymph nodes. The soft tissues are within normal limits. No free air, no osseous
abnormalities visualized.
Pelvis: Prostate and seminal vesicles are normal. The bladder is normal in appearance. Vasculature of
pelvis is unremarkable. No pathologically enlarged lymph nodes. No osseous abnormalities.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Include all medical, nursing,
multidisciplinary treatments and procedures, such as diet, vitals, activity, scheduled diagnostic tests, consults,
accu checks, etc. Also provide rationale and frequency if applicable.)
The patient is currently NPO. His vitals on 2/13/15 read a temperature of 98, blood pressure of 127/76,
2SPO2 of 98%, respirations of 18, pulse of 99, and blood glucose of 82. The patient also had a new peripheral IV placed in
the patients left arm 1/13/15 at 1200 because previous IV was leaking. The patient is also ambulating the floor. He was
ambulating with the assistance of his girlfriend, and was able to tolerate ambulating for 10 minutes.
 8 NURSING DIAGNOSES (actual and potential - listed in order of priority)
1. Risk for infection related to surgical incision associated with invasive surgery from ruptured appendix
2. Acute pain related to surgical intervention as evidence by patient verbalization of pain being a 7/10
3.
4.
5.
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17
± 15 CARE PLAN
Nursing Diagnosis: Risk for infection related to surgical incision associated with invasive surgery from ruptured appendix
Patient Goals/Outcomes
Nursing Interventions to Achieve
Rationale for Interventions
Evaluation of Goal on Day Care
Goal
Provide References
is Provided
The patient remains free of
Encourage and provide wound
Reduces risk of spread of bacteria. Proper hygiene was performed
infection/inflammation by end of
care.
throughout shift to ensure bacterial
shift as evidence by maintaining
spread did not occur.
normal vital signs, absence of
purulent drainage, and absence of
Inspect incision site and dressings. Purulent drainage provides for
Purulent drainage was not present
erythema.
Note characteristics of drainage
early detection of developing
at the incision site upon inspection.
from wound.
infectious process.
Inspect for an increase in
temperature.
A temperature above 99.86 48
hours postoperative suggests
infection; fever spikes that occur
and subside are indicative of
wound infection; very high fever
accompanied by sweating and
chills may indicate septicemia.
The patient’s temperature remained
98 throughout shift, which
indicates a normal temperature.
Monitor patient’s vital signs. Note
onset of fever, chills, diaphoresis,
mentation, and an increase in
abdominal pain
Suggestive presence of infection or
developing sepsis, abscess, and
peritonitis.
The patient’s vitals remained
within normal range. Temperature
of 98, blood pressure of 127/76,
2SPO2 of 98%, respirations of 18,
pulse of 99.
Encourage fluid volume intake by
administering Sodium Chloride
0.9% 500 mL Bolus
Administration of fluids will
replace fluids lost during possible
fever.
The patient received Sodium
Administration of anti-infective
(Metronidazole (Flagyl))
Administration of anti-infective is
used to treat intra-abdominal
infections.
500mg 100mL/hr of Flagyl was administered
intravenously every 24 hours
University of South Florida College of Nursing – Revision September 2014
Chloride 0.9% 500 mL Bolus
continuously.
18
(Metronidazole (Flagyl))
Monitor the patients white blood
count and report abnormal
laboratory values.
Rising WBC indicates body’s
effort to combat pathogens; normal
values: 4000 to 11,000.
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
Bowel sounds will remain
presently active (which signifies
adequate GI motility/function)
throughout entire shift.
Auscultation of the abdomen in all
four quadrants to confirm
gastrointestinal function.
The patient will not develop
abdominal mass or increased pain
throughout shift.
Palpate the abdomen for rigidity
Post appendix rupture, GI motility
can be disturbed due to infection,
rupture of intestines, strangulation
of the bowel and or bowel necrosis
inside the abdomen. Normo-active
bowel sounds and non-rigid
abdomen signifies that no GI
complications arose post-appendix
rupture.
The patient’s white blood cell
count and differential will decrease
to normal limit (between 4000 to
11,000) by the end of shift.
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
Patient will remain aware of signs
of infection of incision site prior to
being discharged.
The nurse will educate the patient
of the signs and symptoms of an
infected incision site like redness,
swelling, as well as oozing from
the incision site.
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
The patients WBC count remained
elevated throughout shift (13.89).
Bowel sounds are actively present
in all four quadrants. No abdominal
rigidity present.
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
Education on the signs and
symptoms of an infection can
promote early detection and
intervention.
Long-term goal cannot be
determined until patients discharge.
(Nursing diagnosis handbook:Evidence-based guide
to planning care 2007)
±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
The dietician will meet with the patient to develop a proper post-op diet. The patient needs to begin a bland, low-fat diet which includes: well-cooked
cereals, mashed potatoes, plain toast or bread, crackers, plain spaghetti, rice, macaroni, cottage cheese, puddings, low-fat yogurt, and low-fat milk.
The patient needs to also increase his hydration status by drinking 6-8 glasses of water a day. The provider as well as the nurse will also meet with
the patient to educate the patient about returning to normal activities. The patient must resume to light activities around the house as soon as possible.
The patient will be educated to not lift anything heavier than 10 pounds until the provider informs the patient that it is okay. Limitations on sports and
strenuous activities 1-2 weeks following discharge. Showering instructions will include to gently wash around the incision site with soap and water,
inspecting for any redness, drainage, or increase in pain. The patient should not bathe in a tub until the incisions are well healed. The patient will also
be educated to wear loose clothing to prevent incision irritation. The provider and the nurse will discuss medications that the patient will be taking at
home, and also inform the patient to not operate a vehicle until he is no longer taking prescribed pain medication. The nurse will also educate the
patient to call his provider when swelling, oozing, worsening pain, as well as unusual redness around the incision site occurs. The patient needs to
also call his provider if a temperature of 100.4 or greater is noticed, if he is experiencing increased abdominal pain, severe diarrhea, bloating,
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19
constipation, and nausea or vomiting. The patient will also be instructed to make a follow up appointment as directed.
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appointments
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
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References
Ackley, B. J. & Ladwig, G. B. (2007). Nursing diagnosis handbook:Evidence-based guide to
planning care (8th ed.). St. Louis: Mosby/Elsevier.
Osborn, K.S, Watson, A.B., Wraa, C.E. (2010). Medical-surgical nursing: Preparation for
practice. Boston: Pearson
Sommers, M.S (2013). Diseases and Disorders: A Nursing Therapeutics Manual (4th ed.)
Philadelphia, PA: F.A. Davis Co.
United States Department of Agriculture. (2015). My plate. Retrieved from
http://www.choosemyplate.gov/index.html
Vallerand, A.H., Sanoski, C.A, Deglin, J.H. (2014). Davis’s Drug Guide for Nurses
(13th ed.) Philadelphia, PA: F.A. Davis Co.
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